Professor of Pediatric Infectious Diseases and Laboratory Medicine; Co-Director of Pediatric Infectious Diseases Virology Clinic. Our research focuses on practical questions related to the prevention of HIV-1 infection in infants, mechanisms leading to shedding of virus in breast milk and genital tract of adults, treatment of drug-resistant virus in children and adults, and understanding mechanisms leading to the persistence of HIV infection.

Over the past 20 years, our group has conducted projects in Peru, Thailand, Mozambique, Kenya and South Africa. These studies aimed to better understand the transmission, selection and persistence of drug-resistant viruses and have included collaborations with other UW, national and international investigators. We have developed economical assays with the goal of making testing accessible to resource-poor communities, to improve the management of HIV infection. Currently, our laboratory located within Seattle Childrens Research Institute (SCRI) focuses primarily on three topics and collaborates broadly with other UW, national and international investigators.

1. Persistence of HIV infection: A major research focus of our work has been to understand the mechanisms that allow HIV to persist despite effective ART. Our group documented that among ART-treated individuals with plasma HIV RNA consistently below the limits of detection included a subset that demonstrated viral evolution, implying low-level viral replication, although the vast majority demonstrated no evolution (Frenkel, JVI, 2003). We were the first to note that transient low-level viremias, or "blips," during ART were usually comprised of populations of identical env and pol sequences (Tobin, JVI, 2005), suggesting production of clonal virus. Our subsequent studies revealed that populations of identical viral sequences in PBMC and sputum (rich in pulmonary macrophages) increase over a decade of ART (Wagner, JVI, 2013), suggesting that clonal proliferation of cells with provirus sustains HIV infection during suppressive ART. Recently, we have documented that identical env sequences have identical integration sites, providing strong supportive evidence that HIV persistence is at least in part due to cellular proliferation, and with ongoing suppressive ART, that these proviruses are increasingly integrated into genes controlling immune functions, the cell cycle or cancers suggesting that interference with these genes expression allows the infected cells to proliferate and/or survive (Wagner, Science, 2014; http://www.sciencemag.org/cgi/content/abstract/science.1256304)

Ongoing projects (R01 AI091550 and R01 AI114348) are focused on understanding whether specific HIV integration events lead to the persistence of HIV DNA that is infectious or defective; use in vitro mutagenesis to determine the effects of specific integration events on cellular function; and on whether during acute HIV infection the antigen specificity of HIV-infected cells that would be targeted for cure in individuals who start ART during this time.

2. Systemic inflammation in HIV-infected individuals: Individuals whose viral replication is suppressed by ART continue to have biomarkers indicative of ongoing diffuse inflammation that accelerates atherosclerosis and cardio- and cerebral-vascular events. Given the timing of HIV acquisition by infected children, substantial morbidity could occur from inflammation despite suppressive ART. We hypothesize that ongoing production of viral RNA or proteins drives inflammation, rather than the alternative hypothesis that immune depletion of gut lymphocytes during acute infection allow bacterial translocation.

An ongoing project (funded by SCRI) aims to determine if low-level production of HIV virions or 16sDNA correlate with immune activation and help develop a short interventional trial to diminish inflammation.

3. HIV Resistance to antiretrovirals: Our group has conducted many studies aimed at better understanding the transmission, selection and persistence of drug-resistant viruses. We have developed economical assays with the goal of making testing accessible to resource-poor communities, to improve the management of HIV infection. Currently, we are conducting a randomized-controlled trial of our oligonucleotide ligation assay (OLA) detection of HIV-drug-resistance pre-ART in Kenya. The primary outcome is the rates of ART-associated suppression of viral replication among subjects randomized to testing or standard-of-care. In addition, we will analyze issues related to transfer of technology and will model the cost-effectiveness of the OLA in ART management. Secondly, with UW bioengineers, we are simplifying this OLA to make a simpler and faster assay.

Ongoing projects (R01 AI100037 and R01 AI110375) aim to better understand the role of specific transmitted mutant codons and define the threshold concentration of mutants that result in virologic failure of ART; to convert our PCR-based assay to an isothermal format; optimize Illumina-based sequencing for use as a clinical assay.

Prevalence of pain and association with psychiatric symptom severity in perinatally HIV-infected children as compared to controls living in HIV-affected households.
20401767
AIDS Care
, 2010 May
: 22(5)640-8
PMCID: PMC3156589

Detection of HIV-1 drug resistance in women following administration of a single dose of nevirapine: comparison of plasma RNA to cellular DNA by consensus sequencing and by oligonucleotide ligation assay.
20181911
Journal of Clinical Microbiology
, 2010 May
: 48(5)1555-61
PMCID: PMC2863880

Association between detection of HIV-1 DNA resistance mutations by a sensitive assay at initiation of antiretroviral therapy and virologic failure.
20377404
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
, 2010 May
: 1397-404

Effectiveness of antenatal group HIV voluntary counseling and testing services in rural India.
17563273
AIDS education and prevention : official publication of the International Society for AIDS Education
, 2007 June
: 19(3)187-97

A proof-of-concept study of short-cycle intermittent antiretroviral therapy with a once-daily regimen of didanosine, lamivudine, and efavirenz for the treatment of chronic HIV infection.
15143462
The Journal of infectious diseases
, 2004 June 1
: 189(11)1974-82

Efficacy and toxicity of antiretroviral therapy using 4 or more agents: application of a strategy for antiretroviral management in human immunodeficiency virus-infected children.
12038889
Archives of pediatrics and adolescent medicine
, 2002 June
: 156(6)568-73

Risk of mother-to-infant transmission of HIV-1 is not reduced in CCR5/delta32ccr5 heterozygotes.
9402070
Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology: Official Publication of the International Retrovirology of Association
, 1997 Dec. 1
: 16(4)243-6

A search for persistent rubella virus infection in persons with chronic symptoms after rubella and rubella immunization and in patients with juvenile rheumatoid arthritis.
8838185
Clinical Infectious Diseases: an official publication of the Infectious Diseases Society of America
, 1996 Feb.
: 22(2)287-94

Berkowitz R, Frenkel LM

Cancer in the HIV-Infected ChildPediatr. Dent
, 1996
: 18127-128

Nickel RT, Bussman J, Frenkel LM, Hylton JR, Miller M, Presler B

Human Immunodeficiency Virus Infection in Children and AdolescentsCommunity Consultants in the Care of Children with Special Health Care Needs. OHSU
, 1996

Effects of zidovudine use during pregnancy on resistance and vertical transmission of human immunodeficiency virus type 1.
7620018
Clinical Infectious Diseases: an official publication of the Infectious Diseases Society of America
, 1995 May
: 20(5)1321-6

A prospective study of the effects of acyclovir treatment on the HSV-2 lymphoproliferative response of persons with frequently recurring HSV-2 genital infections.
2540245
The Journal of Infectious Diseases
, 1989 May
: 159(5)845-50

Frenkel LM, Bryson YJ. 1987

Ontogeny of phytohemagglutinin-induced gamma interferon by leukocytes of healthy infants and children: evidence for decreased production in infants younger than 2 months of age.
3110393
The Journal of Pediatrics
, 1987 July
: 111(1)97-100

Over the past 20 years, our group has conducted projects in Peru, Thailand, Mozambique, Kenya and South Africa. These studies aimed to better understand the transmission, selection and persistence of drug-resistant viruses and have included collaborations with other UW, national and international investigators. We have developed economical assays with the goal of making testing accessible to resource-poor communities, to improve the management of HIV infection. Currently, our laboratory located within Seattle Children's Research Institute (SCRI) focuses primarily on three topics and collaborates broadly with other UW, national and international investigators. 1. Persistence of HIV infection: A major research focus of our work has been to understand the mechanisms that allow HIV to persist despite effective ART. Our group documented that among ART-treated individuals with plasma HIV RNA consistently below the limits of detection included a subset that demonstrated viral evolution, implying low-level viral replication, although the vast majority demonstrated no evolution (Frenkel, JVI, 2003). We were the first to note that transient low-level viremias, or "blips," during ART were usually comprised of populations of identical env and pol sequences (Tobin, JVI, 2005), suggesting production of clonal virus. Our subsequent studies revealed that populations of identical viral sequences in PBMC and sputum (rich in pulmonary macrophages) increase over a decade of ART (Wagner, JVI, 2013), suggesting that clonal proliferation of cells with provirus sustains HIV infection during suppressive ART. Recently, we have documented that identical env sequences have identical integration sites, providing strong supportive evidence that HIV persistence is at least in part due to cellular proliferation, and with ongoing suppressive ART, that these proviruses are increasingly integrated into genes controlling immune functions, the cell cycle or cancers suggesting that interference with these genes expression allows the infected cells to proliferate and/or survive (Wagner, Science, 2014; http://www.sciencemag.org/cgi/content/abstract/science.1256304) Ongoing projects (R01 AI091550 and R01 AI114348) are focused on understanding whether specific HIV integration events lead to the persistence of HIV DNA that is infectious or defective; use in vitro mutagenesis to determine the effects of specific integration events on cellular function; and on whether during acute HIV infection the antigen specificity of HIV-infected cells that would be targeted for cure in individuals who start ART during this time. 2. Systemic inflammation in HIV-infected individuals: Individuals whose viral replication is suppressed by ART continue to have biomarkers indicative of ongoing diffuse inflammation that accelerates atherosclerosis and cardio- and cerebral-vascular events. Given the timing of HIV acquisition by infected children, substantial morbidity could occur from inflammation despite suppressive ART. We hypothesize that ongoing production of viral RNA or proteins drives inflammation, rather than the alternative hypothesis that immune depletion of gut lymphocytes during acute infection allow bacterial translocation. An ongoing project (funded by SCRI) aims to determine if low-level production of HIV virions or 16sDNA correlate with immune activation and help develop a short interventional trial to diminish inflammation. 3. HIV Resistance to antiretrovirals: Our group has conducted many studies aimed at better understanding the transmission, selection and persistence of drug-resistant viruses. We have developed economical assays with the goal of making testing accessible to resource-poor communities, to improve the management of HIV infection. Currently, we are conducting a randomized-controlled trial of our oligonucleotide ligation assay (OLA) detection of HIV-drug-resistance pre-ART in Kenya. The primary outcome is the rates of ART-associated suppression of viral replication among subjects randomized to testing or standard-of-care. In addition, we will analyze issues related to transfer of technology and will model the cost-effectiveness of the OLA in ART management. Secondly, with UW bioengineers, we are simplifying this OLA to make a simpler and faster assay. Ongoing projects (R01 AI100037 and R01 AI110375) aim to better understand the role of specific transmitted mutant codons and define the threshold concentration of mutants that result in virologic failure of ART; to convert our PCR-based assay to an isothermal format; optimize Illumina-based sequencing for use as a clinical assay.

Seattle Children’s provides healthcare without regard to race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry) or disability. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.